Cure odontoiatriche prima della radioterapia ad intensità modulata
Upcoming SlideShare
Loading in...5

Cure odontoiatriche prima della radioterapia ad intensità modulata






Total Views
Views on SlideShare
Embed Views



1 Embed 2 2


Upload Details

Uploaded via as Adobe PDF

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
Post Comment
Edit your comment

    Cure odontoiatriche prima della radioterapia ad intensità modulata Cure odontoiatriche prima della radioterapia ad intensità modulata Document Transcript

    • Studer Gabriela1 Risk-adapted dental care Glanzmann Christoph1 Studer Stephan P2 Grätz Klaus W2 prior to intensity-modulated Bredell Marius2 Locher Michael3 radiotherapy (IMRT) Lütolf Urs M1 Zwahlen Roger A2 Results 1 Clinic for Radiation Oncology, University Hospital, Zurich 2 Clinic for Oral and Maxillofacial Key words: dental care before radiotherapy, osteoradionecrosis Surgery, University Hospital, Zurich 3 Clinic of Dentistry, Oral Medicine and Gnathic Surgery, Clinic for Oral Surgery, Center of Dental and Oral Medicine, University of Zurich Summary Background: At the Clinic for Materials and Methods: In August 2006, RaDC Radiation Oncology at the Zurich University was clinically implemented and has been Corresponding author PD Dr. med. Gabriela Studer, LA Hospital (UniversitätsSpital Zürich [USZ]), used for all HNT patients prior to IMRT since RadioOnkologie AN 16 head-and-neck tumor (HNT) patients have then. Before that (01/2002–07/2006), dental UniversitätsSpital Zürich been treated with intensity-modulated radio- restorations were performed according to the Rämistrassse 100 therapy (IMRT) since 01/2002 (n > 800). This usual procedure. 8091 Zürich E-mail: method causes less damage to normal tissues Results: The rate of grade-2 ORN was similar Tel. 044 255 29 31 adjacent to the tumor, and thus it was possible in the conventionally treated and RaDC groups Fax 044 255 45 47 in the head/neck region to markedly reduce (2% and 1%, resp.); grade-3 ORN had not Schweiz Monatsschr Zahnmed 121: the rate of osteoradionecrosis (ORN), in addi- occurred by the time the analysis was con- 216–222 (2011) tion to reducing the rate of severe xerostomia. ducted. As expected, fewer extractions were Accepted for publication: 18 August 2010 Based on these results, risk-adapted dental performed in the RaDC cohort (no extractions care (RaDC) was adopted by our clinic as the in 47% of the RaDC/IMRT cohort vs. 27% in standard mode of pre-IMRT dental treatment. the IMRT cohort receiving conventional dental The guidelines as formulated by Grötz et al. care). were respected. Conclusion: After considerably less invasive ORN prophylaxis is one of the most important dental treatment, no higher-grade ORN oc- goals of pre-radiotherapy dental care, and the curred and no ORN-related jaw resections ORN rate is a measurable parameter for the were required. Based on the present data, efficacy of dental care, given a certain radia- risk-adapted minimally invasive dental care is tion technique. The aim of the present study recommended before IMRT. was therefore to evaluate the efficacy of RaDC as reflected by the ORN rate of our IMRT pa- tients. Introduction 2010). The greatest clinical advantage of this relatively new technique is that it causes substantially less damage to normal In keeping with international guidelines (Grötz 2003; Shaw tissues while providing equally good or improved tumor con- et al. 2000), all head-and-neck tumor (HNT) patients at our trol rates (Lee et al. 2002; Eisbruch et al. 2003; Eisbruch et clinic since more than two decades have undergone standard- al. 2004; Chao et al. 2004; De Arruda et al. 2006; Puri et al. ized focal evaluation and dental treatment prior to all radiation 2005; Studer et al. 2006a–c, Studer et al. 2007c/d). therapy. Details of the IMRT technique were explained in an earlier Since 01/2002, our HNT patients have been treated with in- publication (Studer et al. 2007a, Tab. I and Fig. 1). Even in tensity-modulated radiotherapy (IMRT) (n > 800, status: March, the first years after implementation of IMRT a diminishment216 Schweiz Monatsschr Zahnmed Vol. 121 3/2011
    • Tab. I (corresponds to Fig. 1) Schematic overview of dental treatment for patients with head-and-neck tumors before/during/after IMRT at the University Hospital Zurich (USZ) Before IMRT During IMRT After IMRT HR Dental treatment as with conventional radiotherapy (RT) – Weekly recall (Bornstein et al. 2001) – Continue recall for the first year (every 6–8 weeks [Bornstein – Dental hygiene – Dental hygiene, motivation, monitoring et al. 2001]) – Treatment of periodontal pockets – Tooth extraction: – Dental hygiene, motivation, monitoring – Tooth extraction: – after consultation with radiotherapist – Dental surgery and periodontal pockets – 10 days prior to RT (Shaw et al. 2000) – antibiotics until wound healing (Shaw et al. 2000) – antibiotics until wound healing (Shaw et al. 2000) – nonvital teeth, apical pathology (Bornstein et al. 2001) – Mucositis prophylaxis (Bepanthen® solution) – atraumatic tooth extraction – advanced periodontal disease, deep caries – Candidiasis prophylaxis (Ampho-Moronal®) – grinding down sharp bone edges – smoothing of bone edges and sharp points – Mouth-opening exercises (trismus prophylaxis) – primary mucous membrane coverage – primary wound closure – Maintenance of oral cavity moisture with chamomile/sage – Candidiasis prophylaxis (Ampho-Moronal®) – Tooth-conserving measures rinses (Ø Glandosan® for the dentate [Nicholls et al. 1998]) – Maintenance of oral cavity moisture with chamomile/sage rinses – Treatment of oral lesions (e. g. candidiasis, …) – Application of fluoridation splint 2–3 /d for 5 minutes (Ø Glandosan® for the dentate [Nicholls et al. 1998]) – Construction of a fluoridation splint – Temporary discontinuation of prothesis wear; not with – Application of fluoridation splint 1 /d for 5 minutes – New interim support using permanent soft materials obturators (Shaw et al. 2000) – tooth-conservation measures – Discontinuation of prothesis wear at night (Shaw et al. 2000) – Restoration of masticatory function – implantation ca. 1 year after RT (own data, unpublished) IR/LR – Dental hygiene – Weekly recall (Bornstein et al. 2001) – Continue recall (every 6–8 weeks [Bornstein et al. 2001] for – Treatment of periodontal pockets – Dental hygiene, motivation, monitoring the first year) – No extraction of teeth if: – Mucositis prophylaxis (Bepanthen® solution) – Dental hygiene, motivation, monitoring – the teeth are otherwise worth conserving – Candidiasis prophylaxis (topische Antimykotika) – Restoration of masticatory function – in NR cases, endodontic treatment is possible instead – Mouth-opening exercises (trismus prophylaxis) – implantation ca. 1 year after RT (own data, unpublished) of extraction – Maintenance of oral cavity moisture – Dental surgery and treatment of periodontal pockets – Selective tooth extractions: – Application of fluoridation splints 2–3 /d for 5 minutes – preoperative antibiotic prophylaxis (1h preoperatively) – 10 days before RT (Shaw et al. 2000) – Discontinuation of prosthesis wear at night (Shaw et – atraumatic tooth extraction – smoothing of bone edges and sharp points al. 2000) – grinding down sharp bone edges – primary wound closure – primary mucous membrane coverage – Conservative dentistry – Tooth-conservation measures – Treatment of oral lesions (e. g. candidiasis, …) – Discontinuation of prothesis wear at night (Shaw et al. 2000) – Construction of a fluoridation splint – Maintenance of oral cavity moisture with chamomile/sage – New interim support using permanent soft materials rinses or substitution with artificial saliva NR – No restrictions placed on dental treatment – No restrictions placed on dental treatment – No restrictions placed on dental treatment – Dental hygiene – Dental hygiene, motivation, monitoring – Treatment of periodontal diseases – Treatment of periodontal pockets – Tooth extraction: – Dental hygiene, motivation, monitoring – Tooth extraction: – of teeth not worth conserving – Extraction of teeth not worth conservingSchweiz Monatsschr Zahnmed – of teeth not worth conserving – Application of fluoridation splint for 5 minutes – Application of fluoridation splint for 5 minutes – 10 days before RT (Shaw et al. 2000) – Manufacture of a fluoridation splintVol. 121 HR: High-risk areas; IR/LR: intermediate- and low-risk areas; NR: no radiation-specific risk3/2011217
    • of the greatly feared osteoradionecrosis (ORN) was observed of radiation. The hypothesis tested was that a constantly low (Glanzmann & Grätz, 1995; Studer et al. 2004; Studer et al. ORN rate would be found in IMRT patients after RaDC com- 2006d; Studer et al. 2007a; Ben-David et al. 2007). In con- pared to IMRT patients who received conventional dental treat- trast to conventional radiation techniques, as applied to a ment. tonsil carcinoma for instance, in which the jawbone is at risk bilaterally due to laterally opposing radiation beams, IMRT can Materials and Methods much more selectively deliver the required dose to the tumor region. During IMRT of tonsil carcinoma the contralateral Patient cohorts jawbone is no longer endangered and the ipsilateral much less In the present study, two patient groups were compared (Tab. III): so. Hence, adapting Grötz’s (Tab. II) guidelines for focused in group 1, from January 2002 to July 2006, 143 HNT patients dental care seemed expedient (Tab. I). This adapted method, were given conventional dental care with standard restorations termed “risk-adapted dental care” (RaDC), has been employed prior to IMRT: 100 patients with oropharyngeal carcinoma and on our IMRT patients since mid-2006 (Studer et al. 2007b). It 43 with a carcinoma of the oral cavity. The mean/median requires that ORN risk areas, i. e. IMRT high-dose areas on the observation period of this group was 40/33 months (5–86). jawbone, be topographically defined by the radiation oncolo- In group 2, between August 2006 and December 2008, 161 gist prior to dental treatment. Areas with low and intermediate patients received IMRT: 106 with oropharyngeal carcinoma and ORN risk are also defined for the dentist, so that dental resto- 55 with oral cavity carcinoma. With all patients risk-adapted den- rations can be performed conventionally in high-risk areas, tal care (RaDC) was performed prior to IMRT. The mean/me- but less invasively in the regions that will receive lower doses dian observation period of this group was 19/13 months (6–44). Radiation Patient ID label oncologist: ……………… Pager Diagnosis / TNM stage: ……………………… Dental Care prior to IMRT UniversitätsSpital Zürich risk definition (to be marked by the responsible radiation oncologist) High Risk area: HR (in red) Intermediate / Low Risk area: MNR (in green) No Risk: NR (in yellow) Klinik für Radio-Onkologie Zürich Dept. Medizinische Radiologie Fig. 1 (corresponds to Tab. I): Zurich University Hospital’s internal form for marking (IMRT dosage-dependent) individual risk areas for dental treatment before intensity-modulated radiation therapy (IMRT). The risk areas (high, intermediate/low, no risk of jaw osteonecrosis) for each patient are marked by the radiation oncologist as the basis for the dental treatment planned (see Tab. I).218 Schweiz Monatsschr Zahnmed Vol. 121 3/2011
    • Tab. II Dental care of patients receiving radiotherapy for head-and-neck tumors (Grötz K A, Strahlenther Onkol 2003; 179 [4]: 275–278) Before radiotherapy During radiotherapy After radiotherapy Dental treatment Tissue-conserving treatment Tissue-conserving treatment – Removal of hard and soft plaque – Mucosa retractors (reduction of surface – Continuation of fluoride application – Extraction of nonvital, periodontally dose to adjacent mucosa via secondary – Discontinuation of prosthesis wearing for diseased, carious, partially retained teeth irradiation) 3–6 months after irradiation – Conservative treatment of remaining – Fluoridation splint and continuous fluoride – Tooth- or implant-borne prostheses or dentition rinsing maxillary prostheses can be re-inserted – Surgical treatment of – Temporary discontinuation of prosthesis earlier, after mucositis has subsided Conventional radiation therapy – mucosal lesions wearing due to sore spots or denture ulcers – Restoration of masticatory function is often – removal of sharp bone ridges – Mucositis prophylaxis especially due to impossible due to xerostomia or jaw lesions (mylohyoid line) xerostomia (Candida colonization) – Special guidelines for dental surgery after Extent of extractions depends on inclusion – Bepanthen® radiotherapy to avoid osteoradionecrosis: of salivary glands in the irradiated field; four – topical antimycotics – Perioperative, systemic antibiotic prophy- groups: (Nystatin = Moronal®) laxis (e. g., Amoxicillin), at the latest 24 h – Edentulous patients without mucosal – mouth rinses (chamomile, sage, pre-operatively lesions = no pre-irradiation therapy chloramine tea); Sucralfat suspension – Atraumatic tooth extraction without – If conservative treatment is impossible – Diflucan® (local & systemic yeast infections) osteotomy, if possible = total extraction, clearing – Discontinue consumption of external noxae – Removal of sharp bone ridges – Conservative caries treatment possible – alcohol, nicotine – Primary plastic mucosal closure = elective extraction – no hot, spicy, or acidic drinks – Xerostomia treatment – No active caries, good oral hygiene – Dermatitis prophylaxis – Artificial saliva (warning: Glandosan® = no tooth extractions – Mouth-opening exercises, if masticatory = mineral loss; mucine-containing muscles and TMJ lie in irradiated field Saliva-medac® and lysozyme-containing – Xerostomia treatment BioXtra® products) – Ethyol (Amifostin®) or Cumarin/Troxerutin – Salivary gland stimulants Sialor® (Venalot-Depot®) – Mouth-opening exercises against trismus areas, i. e. high ORN-risk areas, prior to treatment, the dentist Tab. III Overview comparing the two subgroups of can use this information to know regions requiring risk-adapted patients. RT: radiotherapy; FU: follow-up; RaDC: risk- dental care in each individual patient (see Studer et al. 2007b ). adapted dental care The patient form used for marking risk areas for RaDC is shown in Figure 1 and Table I. Parameter Group 1 Group 2 n = 143 n = 161 a) High-risk regions: Dental treatment standard RaDC 60 Gy to the mandibular bone and/or > 50 Gy to gingival RT technique IMRT IMRT areas. Timespan of treatment 1/2002–7/2006 8/2006–12/2008 Diagnosis b) Intermediate-risk regions: Oropharynx (n = 206) 100 106 > 45 Gy to the gingiva, mandibular bone < 60 Gy, or: man- Oral cavity (n = 98) 43 55 dibular bone < 60 Gy, and relevant reduction of salivation Average/median caused by irradiating mucous membranes and salivary glands FU time in months 40/33 19/33 (no ORN risk, but increased caries risk – for instance after cer- tain types of cervical irradiation in Hodgkins lymphoma). Only patients at risk of developing ORN – that is, patientswith a tumor of the oropharynx (n total = 206) and the oral c) Low-risk regions:cavity (n total = 98) – were evaluated. Mandible < 60 Gy or only ascending ramus in the RT field, and gingiva < 45 Gy and at least a parotid volume equivalent withMethods an intermediate dose of 26 Gy.The ORN incidence in the clinic’s IMRT cohort since RaDC wasintroduced (08/2006–12/2008, group 2) was compared with d) No radiotherapy-specific risk:the incidence after conventional dental treatment (01/2002– Mandibular bone < 50 Gy, gingiva < 40 Gy, and both parotids07/2006, group 1). We expected to find an unchanged, low outside the RT field (< 10 Gy intermediate dose).incidence of ORN in group 2 vs. group 1, since ORN occurs inareas exposed to high doses (usually at doses > 66 Gy), in which Examination for ORN (Tab. IV) was conducted as part of thelesion extirpation was performed according to the usual stan- routine oncological follow-up examinations (by the clinicsdard. for Oral and Maxillofacial Surgery, ENT, and Radiation Oncol- Based on the various known tolerance thresholds of different ogy, University Hospital, Zurich) that were performed regularlynormal tissues for a given radiation dose, it was possible to 4–6 weeks after completion of treatment, then every 2 todefine the risk level for patients scheduled for oral cavity ra- 3 months during the first 2 years. In suspected or positivelydiation treatment (see below, a–d). Because the radiation on- identified cases of ORN patients are referred to the Clinic forcologist can identify and mark topographic IMRT high-dose Maxillofacial Surgery for further evaluation and treatment. Schweiz Monatsschr Zahnmed Vol. 121 3/2011 219
    • Only three patients in this study group failed to participate 5 cases observed also correspond to the NCI and EORTC classi- in the routine progress check-ups, and therefore could not be fication of a grade-2 ORN. Table Vl presents details on the evaluated. 5 sequester patients. All ORN events were found in the high- dose region. Other, unexpected reactions of the mucosa or Results teeth outside the high-dose areas were not observed; the less invasive tooth restorations outside the high-dose areas in Tumor control RaDC group 2 did not demonstrate any clinically apparent, In 90% of the patients, chemotherapy (Cisplatin or Cetuximab) unfavorable results. was also performed simultaneously. At the last performed fol- low-up examination (“last time seen”), 74% of the patients Tooth extractions were living tumor-free, 12% were living with cancer, 12% had Table VII lists the number of teeth extracted in each group. As died of cancer, and 3% had died of other causes. The 2-year expected/by definition, fewer teeth were extracted in the RaDC local control rate of the entire patient group was 85% among cohort. In this context, the clinically relevant (but not quanti- patients with oropharyngeal cancer, and 65% among patients fied) fact must be mentioned that almost no radiation plann- with cancer of the oral cavity. ing computed tomography (“planning CT”) had to be delayed due to pronounced facial soft-tissue swelling after multiple ORN incidence extractions performed as part of the prior dental care. This was, ORN incidence is shown in Table V. The rates of grade-2 ORN however, frequently the case in the period of conventional (sequester formation) were identical in groups 1 and 2; all dental treatment (group 1), with an ensuing delay of 1 to 2 weeks until the swelling had gone down; thus, the start of radio- Tab. IV Grades of osteoradionecrosis (Glanzmann & therapy was also delayed. Grätz 1995) In addition, a tendency of more frequently possible dental rehabilitation was observed (no statistical analysis of these Classification of osteoradionecrosis (ORN) by grade retrospective data). Grade Event 1 Exposed bone without signs of infection for at least Discussion 3 months In addition to severe xerostomia, ORN is the most important 2 Exposed bone with signs of infection or sequester, but not grades 3–5 criterion for radiation tolerance in oral cavity and oropharyn- geal carcinoma patients, and is the main justification for 3 Osteonecrosis, treated with mandibular resection, with consistently performing dental treatment prior to the start of satisfactory result radiotherapy. Comprehensive dental and/or oral surgery treat- 4 Osteonecrosis with persistent problems despite mandibular ment prior to radiotherapy in the orofacial region is of funda- resection mental importance in the prevention of osteonecrosis of the 5 Death due to osteoradionecrosis irradiated jaw. ORN has been variously classified according to different definitions in earlier publications. In our clinics, the classifica- Tab. V Occurrence of osteoradionecrosis (ORN) after tion by Glanzmann and Grätz is used (Glanzmann & Grätz conventional or risk-adapted dental care (RaDC) 1995, Tab. lV). The advantage of this classification vs. that of conventional risk-adapted EORTC (LENT/SOMA) or NCI (Jereczek-Fossa et al. 2002) is 1/2002–7/2006 8/2006–12/2008 Total its connection to therapeutic and clinical consequences; n = 143 n = 161 n = 304 nevertheless, grade-2 events mutually correspond in all of the Grade-1 ORN 0 0 0 named classification systems. Grade-2 ORN 3 2 5 (1.6%) With the radiotherapeutic technology of the past the re- quired tumor dosage was chiefly delivered via laterally opposed Grade-3 ORN 0 0 0 fields, which also simultaneously irradiated most of the oral Tab. VI Details on the 5 patients with grade-2 ORN: comparable grade-2 ORN rates in oropharyngeal and oral-cavity cancer patients with 2% (4/206) vs 1% (1/98), resp. Diagnosis Stage ORN location ORN therapy outcome Occurrence Duration after IMRT (months) 1 Oropharynx cT4cN2c Boost region O Healed 12 20 2 Oropharynx cT3cN2b Boost region Partial decortication Regenerated 4 5 3 Oropharynx cTcN2b Boost region O Healed 22 30 4 Floor of mouth pT2pN0 Boost region Partial decortication Regenerated 0 6 5 Oropharynx cT3cN2b Boost region O Healed 6 20 Patients 4 and 5 received risk-adapted dental care (RaDC) before IMRT In terms of local radiation dose, nothing remarkable was found compared to other patients without ORN. The 5 events were located in region 37/retromolar left/31–32/37/47. pTpN: postoperative stage cTcN: definitive IMRT without prior surgery220 Schweiz Monatsschr Zahnmed Vol. 121 3/2011
    • Tab. VII Retrospective overview of the number of teeth extracted during dental treatment prior to radiotherapy and during dental care after IMRT (dental implants, removable partial or complete dentures) Parameter Conventional dental care RaDC (IMRT group 1) (IMRT group 2) Edentulous patients 17% 15% Dentate patients – no extractions 27% 47% – 1–3 teeth extracted 36% 29% – 4–15 teeth extracted 37% 24% Dental rehabilitation 23% 36%cavity and/or jawbone. This resulted in a greater radiation mor, and is performed as soon as possible after dental treat-impact on the jawbone, associated with a higher ORN rate, ment. This CT is conducted with a custom-modelled fixationthan seen today in the IMRT era; accordingly, the entire den- facial mask made of plastic (for the purpose of reproduciblytate jaw usually had to be considered a “region at risk” and positioning the patient over the weeks of treatment, everycorrespondingly dentally treated. IMRT is a method which radiotherapy session is carried out using this mask). If the maskmakes it possible to restrict the high-risk region to the volume is made on a swollen face, it will be loose after the swelling hasof jawbone adjacent to the tumor. IMRT enabled the ORN rate subsided; both the fixation mask and the millimeter-exactto be reduced from ca. 5–10% to 1% (Glanzmann & Graetz, radiation plan are thus rendered worthless.1995; Studer et al. 2004; Studer et al. 2006d; Studer et al. Experience has shown that careful manipulations/interven-2007a; Ben-David et al. 2007), a success of considerable rele- tions on the jawbone and its mucous membrane covering arevance in the attempt to reduce late complications of radiation well tolerated after radiation doses of up to ~ 50 Gy, but attreatment. The “focussed” high-dose exposure and the pro- doses over > 50 Gy, invasive interventions are accompanied bynounced drop in the ORN rate after IMRT shown in our patients an increased risk of ORN and lower tissue tolerance. If thein 2006 indicated the logic of also keeping dental treatment status of the remaining dentition and surrounding tissues is“focussed”, which our center has therefore done since mid- better, this greatly improves the outlook for any subsequent2006. Table I shows the steps of dental treatment in RaDC: ad- dental care, which in turn positively influences the tumoraptation of methods to the local risk for jawbones and soft tis- patient’s quality of life (Zwahlen et al 2008). The retrospectivesues before/during/after IMRT; Table II summarizes the standard data on dental treatment seems to confirm this (Tab. VII).procedures which have existed up to now. As already mentioned, From an economic point of view, avoiding a grade-3 orthe main difference lies in the focussed approach of RaDC. -4 ORN amounts to a savings of about € 30,000 (based on Swiss After an observational period of over 3 years since introduc- conditions); the improved possibilities for dental treatmenting the guidelines for pre-IMRT RaDC, no detrimental effects and the advantages of more remaining teeth are more difficulthave yet been found in patients of group 2, most importantly, to express in terms of costs. Nevertheless, the health advan-no increase in ORN incidence compared to the IMRT group 1, tages and improved quality of life for the patients are indisput-which in the previous years had undergone focal treatment ac- able. It is interesting to note that the incidence of bisphospho-cording to the conventional standard. Although the duration nate-associated osteonecrosis currently considerably exceedsof observation differed in the two groups, the results are con- that of ORN after IMRT (18.6%, Walter et al. 2008; Dannemannsidered reliable because both groups are IMRT cohorts, i. e., it et al. 2008 ).was possible to very conservatively treat jawbones in bothgroups and include only relatively low volumes of bone in the Conclusionhigh-dosage area. Thus, due to the use of the IMRT technique,an increase in ORN was not expected. As already mentioned, Following much less invasive dental treatment, no higher-dental treatment in the high-risk regions in the RaDC groups grade ORN or ORN-related jaw resections occurred in our IMRTwas also performed in accordance with the general standard. patient cohort, as before. The more invasive standard guide-Less invasively treated intermediate or low-risk areas by defini- lines for dental treatment prior to radiotherapy which havetion receive intermediate or very low radiation doses, so that, been valid up to now no longer appear justifiable for IMRTtheoretically, only limited side-effects are expected in these patients. Based on the data presented here, a risk-adapted, lesstissue areas in RaDC group 2. In fact, 3 years of RaDC experi- invasive approach to pre-IMRT dental care is recommended.ence confirmed this. However, due to the paucity of data inliterature, comparisons cannot be made. Résumé Thanks to RaDC, it was possible to reduce the number of oreven totally avoid tooth extractions in the majority of patients Introduction: L’IMRT est implémentée au Département de(50% more patients with no extractions, Tab. VII), since IMRT radio-oncologie de l’Hôpital de Zurich depuis 2002. Outre unecreates more low- and intermediate-risk areas (that would diminution de la xérostémie, son avantage principal dans lespreviously have been high-dose areas), allowing less invasive régions de la tête et du cou réside dans une réduction substan-dental treatment to be performed. tielle du RON (de ~ 5–10% à ~ < 1%). In this context, the rarity of facial swelling after RaDC is also Les procédures standards lors des soins dentaires préradio-clinically relevant. This is yet another advantage of RaDC, thérapeutiques ont été ajustées afin d’être moins invasivessince time is no longer lost waiting for swelling to abate: the pour les patients soumis à l’IMRT depuis août 2006.planning CT serves as the basis for computer-assisted 3-dimen- Patients et méthode: Cet article présente les résultats d’unesional calculation of radiation dose delivery to the tissues/tu- période d’un suivi de 3 ans pour des patients qui ont reçu des Schweiz Monatsschr Zahnmed Vol. 121 3/2011 221
    • soins dentaires adaptés aux risques avant l’IMRT pour des currence de degré 3, et pas de résection de la mandibule), et cancers de la tête et du cou (n = 161). Des patients traités avec moins d’extractions dentaires grâce au traitement dentaire des soins dentaires standards (n = 143) avant l’IMRT de 01/2002 adapté aux risques. à 07/2006 ont servi de contrôle. Conclusion: Sur la base des données présentées ici, le traite- Résultats: Les analyses du RON ont révélé des taux d’inci- ment dentaire adapté aux risques est fortement recommandé dence égaux pour les deux périodes (1,5% degré 2, pas d’oc- pour les patients soumis à l’IMRT. References De Arruda F F, Puri D R, Zhung J, Narayana A, Glanzmann C, Grätz K W: Radionecrosis of the c) Studer G, Furrer K, Davis J, Stöckli S, Zwahlen A, Wolden S, Hunt M, Stambuk H, Pfister D, Kraus D, mandibula: a retrospective analysis of the inci- Lütolf U, Glanzmann C: Postoperative IMRT Shaha A, Shah J, Lee N Y: Intensity-modulated dence and risk factors. Radiother Oncol 1995; in head and neck cancer. Radiat Oncol 2006, radiation therapy for the treatment of oropha- 36 (2): 94–100 1 (1): 40 ryngeal carcinoma: the Memorial Sloan-Ket- Grötz K A: Zahnärztliche Betreuung von Patien- d) Studer G, Studer S P, Zwahlen R A, Huguenin P, tering Cancer Center experience. Int J Radiat ten mit tumortherapeutischer Kopf-Hals-Be- Grätz K W, Lütolf U M, Glanzmann C: Osteora- Oncol Biol Phys 2006; 64 (2): 363–373 strahlung. Gemeinsame Stellungnahme der dionecrosis of the mandible: minimized risk Ben-David M A, Diamante M, Radawski J D, Deutschen Gesellschaft für Zahn-, Mund- und profile following intensity-modulated radiation Vineberg K A, Stroup C, Murdoch-Kinch C A, Kieferheilkunde, Deutschen Gesellschaft für therapy (IMRT). Strahlenther Onkol 2006; 182 Zwetchkenbaum S R, Eisbruch A: Lack of osteo- Radioonkologie MPuS, Abstimmung mit dem (5): 283–288 radionecrosis of the mandible after intensity- Vorstand der Deutschen Gesellschaft für Zahn- a) Studer G, Grätz K W, Glanzmann C: In response modulated radiotherapy for head and neck heilkunde. (Dental care for patients with anti- to Dr. Merav A. Ben-David et al. (“Lack of os- cancer: likely contributions of both dental care neoplastic radiotherapy of the head and neck.) teoradionecrosis of the mandible after IMRT”, and improved dose distributions. Int J Radiat Strahlenther Onkol 2003; 179 (4): 275–278 Int J Radiat Oncol Biol Phys 2007). Int J Radiat Oncol Biol Phys 2007; 68 (2): 396–402 Jereczek-Fossa B A, Orecchia R: Radiotherapy- Oncol Biol Phys 2007; 68 (5): 1583–1584 Bornstein M, Buser D, Filippi A: Concepts of pre- induced mandibular bone complications. Can- b) Studer G, Glanzmann C, Studer S P, Grätz K W, vention and therapy of radiation-induced side cer Treat Rev 2002; 28: 65–74 Lütolf U M, Zwahlen R A: Recommendations effects. Schweiz Monatsschr Zahnmed 2001; Lee N, Xia P, Quivey J M, Sultanem K, Poon I, for dental care prior to intensity-modulated 111 (8): 962–977 Akazawa C, Akazawa P, Weinberg V, Fu K K: Inten- radiotherapy (IMRT). Adaptation of the Uni- Chao K S, Ozyigit G, Blanco A I, Thorstad W L, sity-modulated radiotherapy in the treatment versity Hospital Zurich (USZ) guidelines. Deasy J O, Haughey B H, Spector G J, Sessions of nasopharyngeal carcinoma: an update of Schweiz Monatsschr Zahnmed 2007; 117 (6): D G: Intensity-modulated radiation therapy for the UCSF experience. Int J Radiat Oncol Biol 637–647 oropharyngeal carcinoma: impact of tumor Phys 2002; 53 (1): 12–22 c) Studer G, Zwahlen R A, Grätz K W, Davis B J, volume. Int J Radiat Oncol Biol Phys 2004; Puri D R, Chou W, Lee N: Intensity-modulated Glanzmann C: IMRT in oral cavity cancer. 59 (1): 43–50 radiation therapy in head and neck cancers: Radiat Oncol 2007; 2: 16 Dannemann C, Grätz K W, Zwahlen R A: Bisphos- dosimetric advantages and update of clinical d) Studer G, Lütolf U M, Glanzmann C: Loco- phonate-induced osteonecrosis of the jaws – a results. Am Journal of Clinical Oncology 2005; regional failure analysis in head-and-neck guide to diagnosis, therapy and prevention of 28 (4): 415–423 cancer patients treated with IMRT. Strahlen- BON in dental practice. Schweiz Monatsschr Shaw M J, Kumar N D, Duggal M, Fiske J, Lewis D A, ther Onkol 2007; 183 (8): 417–423; discus- Zahnmed 2008; 118 (2): 113–123 Kinsella T, Nisbet T: Oral management of pa- sion 424–425 Eisbruch A, Marsh L H, Dawson L A, Bradford C R, tients following oncology treatment: literature Walter C, Al-Nawas B, Grötz K A, Thomas C, Teknos T N, Chepeha D B, Worden F P, Urba S, review. Br J Oral Maxillofac Surg 2000; 38 (5): Thüroff J W, Zinser V, Gamm H, Beck J, Wagner Lin A, Schipper M J, Wolf G T: Recurrences near 519–524 W: Prevalence and risk factors of bisphospho- base of skull after IMRT for head-and-neck Studer G, Grätz K W, Glanzmann C: Osteoradio- nate-associated osteonecrosis of the jaw in cancer: implications for target delineation in necrosis of the mandibula in patients treated prostate cancer patients with advanced disease high neck and for parotid gland sparing. Int with different fractionations. Strahlenther treated with zoledronate. Europ Urol 2008; J Radiat Oncol Biol Phys 2004; 59 (1): 28–42 Onkol 2004; 180 (4): 233–240 54:1066–1072 Eisbruch A, Ship J A, Dawson L A, Kim H M, a) Studer G, Lütolf U M, Davis J B, Glanzmann C: Zwahlen R A, Dannemann C, Grätz K W, Studer G, Bradford C R, Terell J E, Chepeha D B, Teknos IMRT in Hypopharyngeal Tumors. Strahlen- Zwahlen D, Moergeli H, Drabe N, Büchi S, T N, Hogikyan N D, Anzai Y, Marsh L H, Ten Haken ther Onkol 2006; 182 (6): 331–335 Jenewein J: Quality of life and psychiatric mor- R K, Wolf G T: Salivary gland sparing and im- bidity in patients successfully treated for oral proved target irradiation by conformal and in- b) Studer G, Huguenin P, Davis J, Kunz G, Lutolf U, cavity squamous cell cancer and their wives. tensity modulated irradiation of head and neck Glanzmann C: IMRT using simultaneously inte- J Oral Maxillofac Surg 2008; 66 (6): 1125–1132 cancer. World J Surg 2003; 27 (7): 832–837 grated boost (SIB) in head and neck cancer pa- tients. Radiat Oncol 2006; 1 (1): 7222 Schweiz Monatsschr Zahnmed Vol. 121 3/2011